The changing landscape of specialised commissioning: reasons to be optimistic?

When you think about health inequalities, specialised services might not be the first thing that comes to mind. Specialised services vary hugely, covering services looking after a small number of patients with rare cancers but also treatments like kidney dialysis. The nature of these services mean that fewer people interact with them than, say, general practice, which means that the focus has often been on health inequalities further upstream that affect much larger groups of people.  

However, a number of factors related to specialised services, such as the often long, complicated referral pathways and the expertise being concentrated in a small number of clinicians and locations, means that there is real scope for health inequalities to impact on access and outcomes. The concentration of care in specialist tertiary centres means that it can be harder for people who aren’t able to, or can’t afford to, travel long distances to get to their appointments. There are also often long waits to access specialists, who are often the final point of a pathway rather than the first contact, which means people’s conditions can deteriorate while they wait. A recent study found that people living with idiopathic pulmonary fibrosis (IPF), a chronic progressive scarring lung disease which requires specialist treatment, from the most deprived areas had more severe symptoms by the time they saw a hospital doctor and had a poorer survival than those living in wealthier areas. The same study found that people living furthest from specialist ILD services had a shorter life expectancy than those living closer to equivalent service provision. 

Reducing these inequalities is one of the core purposes behind the commissioning of some specialised services being delegated to integrated care boards (ICBs). Since April 2024 ICBs in the North-West, East and Midlands regions of England have been responsible for the commissioning of 59 specialised services, with delegation to remaining ICBs taking place by April 2025. To understand the opportunities and challenges offered by this delegation, The King’s Fund convened a roundtable, sponsored by Boehringer Ingelheim, with attendees including community and voluntary sector leaders, commissioners and clinicians involved in delivering and shaping the commissioning of specialised services.  

What became clear was the opportunity to innovate in the delivery of specialised services in a way that addresses health inequalities by providing as much care as possible closer to patients and places greater value on their time. We heard from a commissioner in the East of England who is delivering specialised interstitial lung disease (ILD) services through a hub and spoke model, which means that patients can access ongoing care closer to home. Digital tools are also enabling patients to be monitored at a distance, for example reviewing a patient’s condition through video-controlled equipment, which reduces the impact of an appointment on patient’s work or caring responsibilities and travel costs. There is also a drive to close the ‘expertise gap’ between specialist centres and locally delivered care. In ILD, a new regional model of care co-developed with patients uses regional networks and a tiered approach to expand access and better integrate care across the whole pathway. This involves upskilling local hospitals through access to specialist workforce and prescribing. An example of this happening in practice is in Merseyside, where the collaborative regional approach means that the specialist centre carries out virtual multidisciplinary reviews to support the local respiratory team to manage patients and reduce the travel burden on patients while ensuring quality of care.  

With greater ICB involvement in specialised commissioning there is also the potential to better utilise local population health data to support service planning along the pathway and reduce issues related to fragmented care. For example, people living with ILD often have social care or mental health support needs for which they could access support locally. We heard that some areas have sought to ensure these needs are met by putting in place care co-ordinator roles to help patients to navigate access to local services. This is part of breaking down silos and looking at people’s needs holistically to ensure resources are being invested in the most optimal way to improve quality, reduce health inequalities and improve value.  

A few challenging realities were also part of the conversation, foremost among these were questions about the headspace and finances of ICBs. Do ICBs have the capacity to focus on the real potential of a change in approach to specialised commissioning, which would positively impact a smaller patient population, while they are under acute pressure to deliver on a number of other big priorities like elective recovery? Does the commissioning expertise exist in ICBs to take on this additional responsibility? These questions were coupled with an acknowledgement of the significant financial pressures ICBs are facing, with the need to have a balanced budget dominating conversations about investment in new ways of working. For example, it can be harder to develop a case for expanding the specialist workforce beyond tertiary centres or introducing a care co-ordinator role given the cost involved when many ICBs are already facing deficits.  

Despite these challenges, there was a real sense of optimism in the room about how ICBs will have the opportunity to view and reframe specialised pathways as a whole, rather than in discrete sections and to use this as a driver to close the inequalities gap across the whole pathway. This is an area that The King’s Fund will continue to track as commissioners prepare for full delegation in April 2025.  

Date of Prep: December 2024

Job bag Number: NP-GB-105213